CO-119 — Benefit maximum reached
Also seen as: CO-119, PR-119
What it means
The patient hit a plan limit — a visit cap, dollar cap, or annual maximum for this kind of service. Further visits in the period won't be covered. For mental health/substance use benefits specifically, a visit or dollar cap that doesn't apply equally to medical/surgical benefits may violate mental health parity law (MHPAEA/ACA) — so this cap is not necessarily the final word.
Standard definition (paraphrased): The patient has already used up everything the plan allows for this benefit, whether that limit is measured per period or per occurrence.
Why it happens
- • The plan caps behavioral-health visits per year and the cap is reached
- • An annual dollar maximum for the benefit is exhausted
- • The plan limits sessions per diagnosis/episode
Common next steps therapists take
- • Confirm the exact limit and how much has been used
- • Discuss remaining options with the patient (self-pay, a new benefit year, or a documented exception if the plan offers one)
- • If the cap looks like it treats mental health/substance-use benefits more restrictively than medical/surgical ones, a parity-based appeal or complaint to the state insurance regulator may be worth exploring
Educational information only
This page is general educational information, not legal, billing, or medical advice, and not a determination about any specific claim. Denial codes are maintained by the X12 committee and updated periodically. Always verify code meanings, benefits, and requirements directly with the payer and against your own records.
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